Effect of a tailored sepsis treatment protocol on patient outcomes in the Tikur Anbessa Specialized Hospital, Ethiopia: results of an interrupted time series analysis

Abstract

Background Despite improvement, sepsis mortality rates remain high, with an estimated 11 million sepsis-related deaths globally in 2017 (Rudd et. al, Lancet 395:200-211, 2020). Low- and middle-income countries (LMICs) are estimated to account for 85% of global sepsis mortality; however, evidence for improved sepsis mortality in LMICs is lacking. We aimed to improve sepsis care and outcomes through development and evaluation of a sepsis treatment protocol tailored to the Tikur Anbessa Specialized Hospital Emergency Department, Ethiopia, context. Methods We employed a mixed methods design, including an interrupted times series study, pre-post knowledge testing, and process evaluation. The primary outcome was the proportion of patients receiving appropriate sepsis care (blood culture collection before antibiotics and initiation of appropriate antibiotics within 1 h of assessment). Secondary outcomes included time to antibiotic administration, 72-h sepsis mortality, and 90-day all-cause mortality. Due to poor documentation, we were unable to assess our primary outcome and time to antibiotic administration. We used segmented regression with outcomes as binomial proportions to assess the impact of the intervention on mortality. Pre-post knowledge test scores were analyzed using the Student’s t-test to compare group means for percentage of scenarios with correct diagnosis. Results A total of 113 and 300 patients were enrolled in the pre-implementation and post-implementation phases respectively. While age and gender were similar across the phases, a higher proportion (31 vs. 57%) of patients had malignancies in the post-implementation phase. We found a significant change in trend between the phases, with a trend for increasing odds of survival in the pre-implementation phase (OR 1.24, 95% CI 0.98–1.56), and a shift down, with odds of survival virtually flat (OR 0.95, 95% CI. 0.88–1.03) in the post-implementation phases for 72-h mortality, and trends for survival pre- and post-implementation are virtually flat for 90-day mortality. We found no significant difference in pre-post knowledge test scores, with interpretation limited by response rate. Implementation quality was negatively impacted by resource challenges. Conclusion We found no improvement in sepsis outcomes, with a trend for increasing odds of survival lost post-implementation and no significant change in knowledge pre- and post-implementation. Variable availability of resources was the principal barrier to implementation. Trial registration Open Science Framework osf.io/ju4ga. Registered June 28, 2017

Predictors of Septic Shock Mortality at a Tertiary Hospital in Ethiopia: A Prospective Observational Study

“…However, it is di cult to conclude without controlling the effect of other treatment-related factors. Some studies have shown the negative effect of delayed initiation of antimicrobial in determining the outcome of septic shock [9,20]. This effect was absent in our study probably because that antimicrobials were initiated within the rst 3 hours of diagnosis nearly for all cases (95%) in line with the 3-hour sepsis bundle.…”

“…Besides, the absence of well-customized hospital-based protocols for early identi cation and management of septic shock may contribute to higher mortality. In addition to limited knowledge and resources, septic shock mortality in Sub-Saharan Africa is believed to be disproportionately high due to widespread malnutrition, sub-optimally managed comorbidities and higher rates of infectious diseases including HIV and TB [4,5,8,9]. Around 68% of patients had one or more comorbidities and HIV was found in 18.8% of the cases in our study.…”

Contributing Factors and Prevalence of Turnover Intention Among Emergency Department Nurses

“…Choosing to leave your job is a cognitive process, and withdrawal is exhibited by quitting the existing job or pursuing other opportunities (Liu and Raghuram, 2022). In studies conducted worldwide, a high incidence of turnover (ranging from 18 to 68% ) among nurses has been noted (Puchalski Ritchie et al, 2022). In this study, we will analyze the prevalence of turnover intention and factors contributing to it among emergency nurses working in a government hospital.…”

Global emergency care: a quality and safety perspective

“…There is certainly room for more research, and guidelines and education based on that research. Quality and safety improvement in LMIC is challenging because of lack of human resources, as detailed in this negative pre-post sepsis guidelines implementation study in Ethiopia resulting in no outcomes improvement [6].…”